Are the statewide prescription drug monitoring programs—programs that healthcare and healthcare IT leaders are involved in across the country—really helping? An analysis by a healthcare policy researcher that was published in the Aug. 22 Perspective section of The New England Journal of Medicine offers a complicated, nuanced answer to the question.
Writing under the headline, “Prescription Drug Monitoring Programs—Friend or Folly in Addressing the Opioid-Overdose Crisis?” Rebecca L. Haffajee, J.D., Ph.D., M.P.H., begins by noting that “Virtually every U.S. state has implemented a prescription drug monitoring program (PDMP) to address high-risk opioid-prescribing and opioid-seeking behaviors that have contributed to the opioid-overdose crisis. PDMPs — electronic databases that track dispensing of controlled substances — are intended to support clinical practice and monitoring efforts. But given that heroin and illicit synthetic opioids account for an increasing share of the 130 opioid-overdose deaths that occur daily in the United States, many stakeholders have expressed doubts about the utility of PDMPs as well as concerns regarding their potential unintended consequences.”
Dr. Haffajee notes that, since Oklahoma established the first electronic PMDP in 1990, 49 states and the District of Columbia have implemented electronic PMDPs—the lone holdout being Missouri. Further, she notes, “Momentum has favored stronger state PDMP features over time (see graph). Programs increasingly facilitate enhanced clinical use. Stakeholders view PDMPs as a resource for improving treatment decisions and for moderating opioid prescriptions — for instance, identifying cases of harmful polypharmacy (e.g., overlapping opioid and benzodiazepine prescribing) or multiple provider use (seeking controlled substances from multiple prescribers or pharmacies). Most states,” she notes, “originally made PDMP use optional but now require prescribers to register with and use the databases, while also allowing delegates (clinical staff who have access to confidential patient data) to run queries on prescribers’ behalf. Despite these trends, heterogeneity among state PDMPs persists.”
But, she notes, “PDMPs remain controversial. Among the concerns: that “PDMPs might induce a dramatic reduction in opioid-analgesic prescriptions without an equivalent increase in the provision of alternative treatments for patients who are dependent on opioids”; that, some believe, “they infringe substantially on medical practice — a domain in which professional autonomy is paramount”; that some feel there is a conflict between PDMPs’ support of clinical decision-making and their support of law enforcement agencies’ and medical boards’ identification of troublesome prescribers and patients, with privacy concerns implicated by that conflict; and lastly, the question of “whether the current nature of the opioid crisis undermines PDMP utility. PDMPs don’t track sales of heroin and illicit synthetic opioids — drugs that are responsible for a growing share of overdose deaths in the United States (more than 28,000 and 15,000, respectively, in 2017). Modeling studies suggest that further lowering the incidence of prescription-opioid misuse will contribute only marginally to reducing overdoses and that PDMPs could contribute to increased opioid-related deaths in the short term.”
Dr. Haffajee believes that “PDMPs could be more carefully calibrated to maximize clinician, patient, and population interests”; that “[s]tates could integrate nonpharmaceutical data, such as data on emergency department admissions and emergency responder incidents, into PDMPs to highlight additional risk factors for controlled-substance use, including prior nonfatal overdoses”; and that “access to individually identifiable PDMP records by law-enforcement officers should be limited to circumstances when probable cause supports a specific need.” Implementing such changes, she argues, could produce “enduring benefits in terms of safe prescribing and dispensing of opioids and other controlled substances, such as benzodiazepines, that contribute to the larger U.S. drug-overdose crisis.”